Tag: Equity

Born to a Gandhian mother and a forest conservator father, a qualified doctor herself, Dr Mira Shiva chose to live the life of an activist. Single by choice in a man's world, Shiva has not just left her mark but has successfully made a difference to society…

Her journey started from Ludhiana in 1968, when she was doing her MD from Christian Medical College. When Dr Mira Shiva was a student, she observed women were dying during child birth and the college was making efforts to prepare doctors for situations like these. It was in this college that Shiva met Dr Betty Cowan, a Professor of Medicine and Community Health who later became her inspiration. "In her I found a person motivated by community health concerns," says Shiva.

Turning point

Shiva happened to be in Bihar in 1979-80 when there was an outburst of tuberculosis in the area. "There was a spread of tuberculosis and there were no anti TB drugs available in that area. All irrational hazardous combinations were flooding the market. That was the time that I felt the pain in my heart and thought that I must take this up with the chemical ministry," recalls Shiva. This marked the major turning point in her life.

Thereafter, Shiva has never looked back. She knew what she wanted to do next. Confident in her thoughts, she followed her mind. "I always wanted to become a doctor and practice medicine but I also wanted to serve human kind," she says.

Making a difference

Shiva has made many remarkable efforts in order to make this world a better place to live in. She has been associated with civil society bodies and has been part of many government committees representing the voice of masses.

Shiva was a member of the Drug Pricing Review Committee in 2001, as well as the Chemicals Ministry and the R& D Committee in the same year. Besides, she has played an important role as a member of various bodies like the Central Council for Health, National Population Commission, National Advisory Committee on Assisted Reproductive Technologies and National Human Rights Commission. She was also on the Task Force on Safety of Food and Medicine and was Chairperson of the Task Force on Consumer Education. Shiva is also associated with civil society bodies like Health Equity and Society, All India Drug Action Network and Health Action International Asia Pacific. She is a founder member of Peoples Health Movement and a steering committee member of Diverse Women for Diversity.

But is it easy for a woman activist to fight for rights of women and poor people amidst powerful men? "There are always men to de-legitimise my presence but I am always too firm to make my way and tell them my purpose to be there. The fact that I happened to be a woman is not so important to me," declares Shiva. She has rather learned from her experience to handle people and she feels it is important for every woman to do so too. "It is important to understand that you are saying what you are saying and being a woman does not mean that you are asking for a favour," she adds.

For namesake

The lady, who named herself after Mira Bai, says that she knew that she was born to become a rebel. "I named myself after Mira Bai because people tried to kill her in three different ways but failed. I draw my inspiration from there," she says. However, born to a family with liberal thoughts, Shiva gets her strength from her Gandhian mother, who was a writer and faced odds in her life as well, as well as her grandfather, who had set up a school for girls in rural areas. Her parents were very supportive of her decisions and gave her the freedom to choose. "I got it as a sanskar that I am no less than others and that there is no difference between a boy and a girl. If you underestimate me as a girl you are asking for trouble," she declares.

But women often face attacks on their identity from a patriarchal society. So did Shiva. "I have been repeatedly addressed as ‘Mrs Mira Shiva’ and by people who know my status but each time I used to make it a point to raise my voice and correct them …I will tell them I am not Mrs Mira Shiva but Dr Mira Shiva…It has something to do with my identity and it is important to me. People try to weaken you through such means. They would tell me that I am acting non-professional and speaking for a certain section which is not true," she says. Shiva points out that men occupying positions of power expect women to follow instructions and agree with them on whatever they say, so she was naturally not like by them. But she wonders, had she been born a man , then would the reaction from men be similar? The question remains unanswered …

Irene has over 15 years experience in public health practice, research and teaching. She was a professor in the University of Utrecht as holder of the Prince Claus Chair in equity and development from 2008 to 2010. Her interests are in health policy development and implementation, public health leadership and health policy and systems research. She is currently the regional Director of Health Services, Ghana Health Service in the Greater Accra Region and also teaches part-time in the HPPM department School of Public Health of the University of Ghana, Legon. She is Chair of the Scientific and Technical Advisory Committee (STAC) of the Alliance for Health Policy and Systems Research, WHO Geneva.

1ITS Project, Center for Integrated Services and Program Science, Futures Group International India Pvt Ltd, Chandigarh, India, 2ITS Project, Center for Integrated Services and Program Science, Futures Group International India Pvt Ltd, New Delhi, India, 3Centre for Health Informatics, National Institute of Health and Family Welfare, New Delhi, India, 4ITS Project, KIT, Netherlands, New Delhi,India, 5ITS Project, Center for Integrated Services and Program Science, Futures Group International India Pvt Ltd, New Delhi, India.

Country - ies of focus

India

Relevant to the conference tracks

Health Workforce

Summary

Skills based training of health personnel and task shifting have been two strategies under NRHM to address the shortfall of human resources in health in India. Training Management Information system, a web based “single window” software application was developed to create a nationwide database for health personnel that can be updated in real time at the training centres. The TMIS software pilot, launched in five states, helps collate individual level training information about each health personnel as well as health facility level information about the availability of trained health personnel. The TMIS facilitates monitoring and decision making for the policy makers and program managers.

What challenges does your project address and why is it of importance?

India finds itself ranked 52 of the 57 countries facing a Human Resources for Health (HRH) crisis. India’s major limitation has been in the production and distribution of human resources across multiple levels of care. As of March 2010, the overall HRH shortfalls range from 63% for specialists to 10% for allopathic doctors, and 9% for Auxiliary Nurse Midwives (ANMs), respectively.
Health curricula in the country have not kept pace with the changing dynamics of public health, health policies and demographics. The ANM and General Nursing & Midwifery (GNM) curricula have only twice been revised in the past 40 years. Current medical and nursing graduates in the country, trained in urban environments, are ill-prepared and unmotivated to practice in rural settings.
The health reforms under National Rural Health Mission (NRHM), include a focus on skills based training of existing health staff and task shifting to meet the shortfall for the health workforce. However, there are challenges in terms of identifying appropriate candidates for trainings, incomplete database on training status of health personnel, equity in professional development opportunities, rational posting of trained personnel and post training performance follow up of trained personnel.

How have you addressed these challenges? Do you see a solution?

The National Institute of Health and Family Welfare is the nodal agency for conducting, coordinating and monitoring performance of various trainings conducted under NRHM. The EU supported Institutional and Technical Support Project (ITS) is providing technical assistance for institutional capacity strengthening of the National and eight State Institutes of Health and Family Welfare (NIHFW, SIHFWs). The Ministry of Health and Family Welfare (MoHFW) identified quality assurance of trainings as one of the expected outputs under the ITS project which would strengthen the NIHFW and SIHFWs.
The Training Management Information System (TMIS) is a web based software application, developed by the ITS project, for nationwide database of skilled human resource to strengthen the public sector health delivery system. The TMIS will help to plan and manage RCH trainings under NRHM, rationalise deployment of trained personnel in different health facilities and strengthen monitoring of quality of training.
The web based TMIS software help collate individual personnel level training information as well as health facility level information about availability of trained health personnel. The TMIS software has two parts - dynamic and static. The dynamic section automates the data related to human resource, trainers, participants, training centres, health facilities and type of training. The real time trainings’ data is captured, updated and generates district, state and national level training reports. It integrates sms alerts to trainers and participants. The static section includes all the documents related to trainings like training guidelines, training manuals, course content, training calendars, circulars and other relevant online material.
TMIS addresses the problem of the re-entry of existing HR and training data collected over the years in excel format by bulk uploading the same into TMIS software. The TMIS facilitates monitoring and decision making for the policy makers and program managers at all levels. It will help to recommend corrective actions based on the analysis of the human resource skills gap.
In the long run, TMIS will facilitate tracking of the resource pool of trainers and of the trained personnel through GIS mapping facilitating monitoring, better planning and resource optimization. The report generated through the software will help in monitoring and evaluating the achievement in reaching MDGs.

How do you know whether you have made a difference?

The user training and pilot launch of TMIS has been done in five states – Odisha, Haryana, Uttar Pradesh, Karnataka and Andhra Pradesh from April to June 2013. The SIHFWs are the nodal agencies for TMIS management at the state level. In total, 443 district and state level data entry operators were trained on the use of the TMIS software, data preparation, data cleaning and online-entry. The database software built on SQL server platform (using .NET framework) using key variables such as: trainees, trainers, training courses at different levels of health system in India which is available on the NIHFW website. To date, basic human resources data of at least 77 districts from 5 pilot states has been collected by the district data entry operators and centrally uploaded on the software by the team at NIHFW. This uploading of the human resource data is a one time activity which will be followed by online real time updates on personnel trainings. Draft user manuals and technical training documents for TMIS software have been developed. A help desk has been set up centrally at NIHFW for answering queries of the state. The help desk has received on average at least 40 queries per month from 5 states in the last 3 months. The TMIS software has been demonstrated to all national program managers at MoHFW and has been modified to meet the needs of both national and state level authorities.
In the select districts which have started using TMIS, the health department is able to nominate appropriate candidates, facilitate post training placements and name based tracking of health professionals. The sms alerts to the trainers and participants before the trainings and the instant online certificate generation through TMIS has already streamlined the training process and has overcome the limitations of manual compilation of training data in the country. The detailed pilot data report on utilisation and application of TMIS will be available by December 2013 and will be presented in the conference. However, to date all the health authorities at pilot states have shown great enthusiasm and provided positive feedback about the practicability and effectiveness of this application.

Have you or the project mobilized others and if so, who, why and how?

Through the ITS project we have mobilised the resources at the NIHFW and SIHFWs for implementing the TMIS application. The existing staff at NIHFW and SIHFW have been trained as master trainers for training further district data entry operators. Two staff at NIHFW have been identified to act as a help desk for states and support the TMIS tasks of bulk uploading of human resource data. Similarly SIHFW’s nodal officers for TMIS have been identified and state data entry operators have been trained to address minor issues that the district level operators may encounter. The NIHFW and SIHFW infrastructure was leveraged for conducting trainings. With the TMIS deployed at state and district levels, the health authority would be equipped with a useful tool to manage training activities on-site. Further use of TMIS and integration with existing human resources for health database can speed up better manpower management and utilisation.

When your donor funding runs out how will your idea continue to live?

The sustainability plan for TMIS has been developed for 10 years and presented to NIHFW and MOHFW for formal approval. The TMIS sustainability plan specifically aims to: build up a TMIS team in the NIHFW to maintain a national/country wide database of skilled and trained human resources; assist decision makers and stakeholders to perform gap analysis of trained human resource in public health sector delivery system; maintain a Government to Government (G2G) web based application for monitoring and planning of skilled and trained health care providers and create a foundation (if required) to make TMIS cell at NIHFW to become a “centre of excellence” in Health Information Systems. The involvement of policy makers at the national level through regular interaction to exchange inputs into TMIS design, meeting with different program divisions, and the implementation of health facility hierarchy of established ministry level software Health Management Information System (HMIS) into TMIS indicate that TMIS is viewed as useful tool by MoHFW. The MoHFW has expressed their commitment in scaling the application to a national level after the pilots. The Steering Committee meeting, chaired by the Joint Secretaries of MoHFW responsible for training, and NRHM will be allocating financial resources from the next financial year.
Based on the request from MoHFW, ITS team visited a non ITS intervention state of Tamil Nadu to explore the integration of TMIS with existing Human Resource Management Information System. It is planned that further customisation of TMIS at national and state level may even enable the users to get routine statistics on training activities going on at each level, to generate automatic reports as well as get better overview of training needs and relevant demands at each geographic regions. The TMIS would certainly help human resource development and management in India in the long run.

Tobacco use is one of the leading causes of early deaths and is gradually increasing in developing countries like Bangladesh. Bangladesh is on the verge of tobacco epidemic as 16% of total deaths among the people aged 30 years and above is connected to tobacco use. There are many difficulties in mitigating the tobacco menace in Bangladesh despite government laws and regulations. Community level effective communication strategy/techniques were largely absent in providing meaningful information about the harmful effect of tobacco use. icddr,b has develop and tested a package of communication techniques to reduce tobacco use at the community level.

Background

Tobacco use has long been a leading contributor to premature death, and causes about 9% of deaths worldwide. Rates of smoking are increasing in many low-income and middle-income countries including Bangladesh. The proportion of tobacco-attributable deaths from tobacco use increases as the number of deaths increases. According to WHO, nearly 6 million people die from tobacco-related causes every year. If present patterns of use persist, tobacco use could cause as many as 1 billion premature deaths globally during the 21st century. Tobacco use, in particular smoking cigarettes and bidis, are common habits among the general male population in Bangladesh. Smoking related diseases such as pulmonary diseases, stroke, ischemic heart disease etc. are well documented. Smokers have a greater risk of dying from pulmonary tuberculosis as compared to non-smokers. Tobacco related illnesses accounted for 16% of the total deaths among the population of Bangladesh who are aged 30 years and above, which is about 25% of deaths in men and 7.6% in women. Smoking is also positively linked with the illicit drug use in Bangladesh. The cost of tobacco consumption at the national level is found to be associated with the increased health-care costs and loss of productivity due to illnesses and early deaths.

Objectives

The objectives of the project are to document the effectiveness of various communication techniques in reducing the tobacco use in a targeted population and design a future intervention based on the effective techniques.

Methodology

The project carried out in Chakaria, a rural sub district of Cox’s Bazar in Bangladesh where icddr,b is active in research and development activities since 1994. Fifteen villages from three unions were selected for the intervention and the same number were chosen for comparison. We have adopted various interventions in the form of Othan Baithaks or household courtyard meetings, peer group meetings, transmitting cell phone messages, counselling tobacco users through mobile phones and motivating village doctors to disseminate messages to the patients. The target audience is women and men aged 15 years and above. During the intervention, a female/male health worker showed/discussed the potential harmful effects of smoking and the dangers of passive smoking, emphasizing the idea that smokers not only put themselves at risk of serious health problems but also the people around them who are mainly family members. The health worker also transmitted the messages to all mothers that a developing baby can be affected by tobacco smoke if the mother smokes or if she is exposed to tobacco smoke during pregnancy. A video showing the harmful effects of tobacco use and large pictorial messages were displayed to communicating the message to smokers and non-smokers. Data were collected from follow-up, and mobile counselling, video sessions and process documentations were used for analyzing and interpreting the results.

Results

During January 2011-June 2103 intervention period total 9760 women/men aged 15 years and above from 1600 households participated in the Othan Baithaks and organized video sessions. 1482 households had mobile phones and 78% of these households were contacted for counselling through mobile phone. Among the population, men were most likely to use tobacco than women. Among the targeted population 1173 (12%) quit tobacco, 728 (7.5%) committed to quit and 1482 (15%) persons reduced the use of tobacco compared to their daily uptake.

Conclusion

Community level intervention can be an effective mechanism to reduce tobacco use along with government regulatory measures to combat tobacco menace. The regulatory framework can be designed such a way that the community can be engaged, informed and create a platform to use this as a prevention strategy.

Bangladesh is one of the 57 countries with a serious shortage of trained doctors, paramedics, nurses and midwives. Village doctors, a group of informally trained practitioners in modern drugs, are the dominant health care providers in the rural area. Village doctors, trained by the Centre for Equity and Health Systems (icddd,b) who had achieved an acceptable level of performance in dispensing drugs and in other desired areas related to the practice, were branded as ShasthyaSena (health soldier). The ShasthyaSenas took part in an intervention that combined their competence with that of qualified physicians through an mHealth call centre with the objective of bringing better health services to the rural community they served in.

Background

Bangladesh is one of the developing countries where 80% of the population lives in rural areas. The village doctors were most prominent contact person for consultation for any illness by the rural poor in Bangladesh. 53% of the rural population resorted to village doctors for their health services. But the village doctors are not recognized by the public sector as authentic health service providers. icddr,b has tried to train the village doctors in order to reduce harmful treatment practices since 2006 in Chakaria. There is a dearth of study regarding the engagement of village doctors or informal healthcare providers in tele-consultation (mHealth) of patients with formal provider. icddr,b operates a project to engage village doctors with the consultations of graduate doctors through mobile phones and with technical guidance from Telemedicine Reference Centre Limited (TRCL) a private entrepreneur in Bangladesh.

Objectives

The objectives of the project were to design a) an appropriate disease management scheme available to the village doctors for on the spot consultation with qualified medical personnel through a mobile phone. The range of management includes prescription by the formal physicians through SMS, prescription drugs supplied by the village doctors and referral to appropriate facilities if needed.
b) A business model aka financial incentive that can compensate village doctors and limit excess profit gained from unnecessary prescriptions.

Methodology

The study was carried out in Chakaria, a rural south east sub-district of Bangladesh. Village doctors were trained on do and don’ts for providing treatment to patients and a membership-based-network involving trained and eligible Village Doctors branded as “ShasthyaSena” (Health Frontiers) was established which give the Village Doctors logos and badges. In 2011 ShaysthaSena’s were trained on the use of mobile phone (mHealth) for consulting with graduate doctors for their patients within a revenue sharing process. A Call Centre was established, eClinic24, to link the informal providers with the formal by (TRCL). TRCL provided technical and expert support for the project. We kept all the details of implementation i.e. inception, modification, challenges, perceptions etc. and periodic process documentation.

Results

During 2011-12 program implementation periods, 110 ShasthyaSenas participated in the training and 55 registered with the eClinic24 system. Of those who registered, the utilization of the services was somewhat low. A total of 415 calls were enacted and only 26 ShasthyaSenas made those calls. 50 calls ended up in receiving prescriptions. Although there was a lot of enthusiasm among the ShasthyaSenas and the community about the mHealth, as the numbers of utilization indicates, the uptake was far below than what was expected. The major reasons for the low uptake of mHealth services mentioned by the ShasthyaSenas revolved around the problem of accessing the call centre, such as doctors not picking up the calls, long waiting period, and problems with the phones the ShasthyaSenas owned.

Conclusion

Despite low uptake at initial program implementation, mHealth can be an effective means of health services in future and ShastyaSenas can be a viable options to engage as the community have confident on them. More research in this field needed by resolving the technical problems encountered during initial phase.

Poor governance in the health sector is negatively influencing service delivery mechanisms in Bangladesh, which in turn results in low utilization of public facilities. Although the principle of strengthening effectiveness and accountability of service provision through ‘participation’ has been introduced in the recently created Community Clinics and the associated Community Groups (CG) in rural Bangladesh, reviews to date have shown very slow progress in this area. The current project strengthened capacity of CGs through providing skilled based training. This enhanced the voice of citizens which inturn improved governance at CCs.

What challenges does your project address and why is it of importance?

Poor governance in the health sector is negatively influencing service delivery mechanism in Bangladesh, which in turn results in low utilization of public facilities. Non-availability of drugs and commodities, imposition of unofficial fees, lack of trained providers and weak referral, feedback and monitoring systems contribute to low use of public facilities in Bangladesh. A number of other factors also adversely influence the service delivery mechanism. One such challenge is the inadequate participation of civil society in decision making processes. Evidence suggests that closed decision making processes in unequal societies can result in priorities that are biased towards elite interests and not adapted to the needs and priorities of the poor, which may have a negative impact on equity and social justice. Although the principle of strengthening effectiveness and the accountability of service provision through ‘participation’ has been introduced in the recently created Community Clinics and the associated Community Groups in rural Bangladesh, reviews to date have shown very slow progress in this area. Out of 13000 Community Groups very few are functional, leading to inadequate participation of the poor in local level planning or initiating accountability.

How have you addressed these challenges? Do you see a solution?

The project has strengthened the Community Groups through providing skilled based training to its members in four upazilas in two districts. It provided relevant information and data including potential sources of funding and information on changes in rules and regulations to CG members. The process contributed to developing self confidence among people in discussing and analysing issues, identifying a problem, visualizing disparities, understanding their entitlements, identifying their duty bearers, articulating issues, developing plans as a team to address their problems, and communicating this properly to the appropriate forum/platform. The project has created a better referral linkage of Community Clinics with Upazila Health Complex (UHC). The patients they refer get special attention and preference at UHC. Due to the monitoring of CG, CC remains open from 9 am to 3 pm six days a week. The greatest success the development of coordination between health care providers and clients, people now conceive as public health care facilities as being their property, the reputation of the CG members in the community has gone up and the utilisation of services and respect for providers at CC has also increased.

How do you know whether you have made a difference?

Clearly this project created opportunities for capacity strengthening of the local political leaders as well as community representatives so that they become better informed on health issues. It contributed to facilitating the relationships of citizens with health providers and governments. This in turn has given a platform to improve the quality of information available to citizens and to raise their voices. The project has created a sense of ownership among the citizens in functioning CG's. Interaction between service providers and patients became informal which increased access to services. It reduced the ‘illegal’ operations such as absenteeism and misuse of drugs.

Have you or the project mobilized others and if so, who, why and how?

The project has created a link between Community Clinics, which is under Ministry of Health and Union Council members, who are under Local government. Union Council Members now attends the monthly meetings of the CG and monitor their functioning.

When your donor funding runs out how will your idea continue to live?

The project will be sustainability even if donor funding is withdrawn, as the community group members are adequately trained and have been empowered to conduct the activities without third party facilitation. A mechanism to generate fund through community mobilisation to meet some expenses as also been created.

Brazil has established a nationwide health system (SUS) aimed at ensuring universal access and has made enormous progress towards this goal over the past two decades. However, a number of studies have shown that certain vulnerable groups often do not have effective access to the services they need. The study analyzes the evolution of the supply and consumption of public healthcare services within the municipality of São Paulo between 2000 and 2011. The results show that there has been equity gains that favored groups living in areas that present the worst socio-economic indices. The paper discusses how municipal health policies and politics helped to guarantee these achievements.

Background

During the 1990’s a new governance structure was forged and contracts were initiated between the federal, state and municipal governments, which defined responsibilities and transparent financing rules for the implementation of the national health policy. At that time the effective institutionalization of the health conferences, a national health council, and the health councils in all twenty-six states and in nearly all of the 5,561 municipalities also took place. Today the national government has an important role in regulating and financing health services, while state and municipal governments are responsible for delivering services and allocating supplementary funding. One major challenge facing the SUS is how to increase the system’s equity as the provision of services is still skewed in favor of wealthier regions and citizens. In particular, the study focus on the difficulties posed in tackling internal equity gaps in mega cities as, despite the fact that these are highly unequal areas, the national policy only focuses on inequalities between regions, states and municipalities. The study explores how municipal politics favored the adoption of policies that helped in guaranteeing a more equitable distribution of public health services in the mega city of Sao Paulo.

Objectives

The study evaluates the redistributive efficiency of the Sao Paulo municipal policies’ adopted between 2001 and 2011. The period covers three municipal terms. The study: 1) follows the distribution of public health services – equipment and service supply - in all the 31 sub-municipalities between 2001 and 2011; 2) describes the health policies implemented by each of the three administrations and explores the rationale for its adoption; 3) tests the plausibility of the assumption that relates, on one hand, the coupled presence of competitive election for local office and citizen participation and, on the other hand, the adoption of innovations that favored greater equity. The main questions we planned to answer were: Did the gap across areas with the highest and lowest Intra-Municipal Development Index narrow during the period? Can we identify how the different strategies adopted by the municipal government in each term worked to reduce or widen this gap? What was the role played by local politics in favoring the adoption of these strategies?

Methodology

The analyses gauge the effect of municipal health policies on indicators of access to public health services. The study was organized in three steps. First, a geographic Information System (GIS) was organized. It contains data from the years 2000 to 2011 on per capita primary appointments of a given submunicipality, the rate of hospital admission per 10.000 residents of a given submunicipality; age, income, and educational level of the submunicipalites’ resident population and the proportion of SUS users and out-of-pocket or private insurance users. The SUS-user is a citizen without a private health insurance, who uses the public health system, which in São Paulo’s case representes 48% of the total population. For primary consultations there is no information to allow for identification of the beneficiary for a given appointment and we assumed a plausible premise that this kind of service tends to be produced in a decentralized fashion and consumed locally. For hospital admissons we worked with the Hospital Admission Authorization (AIH), the means through which healthcare service providers in Brazil are reimbursed. AIH records indicate the zip code of those who used the SUS service which allows for mapping of the consumption of hospitalizations in the sub-municipalities areas. Equity gains have been estimated as the difference between each outcome in the sub-municipalities areas, which are in the highest socioeconomic quartile compared to the lowest quartile. The sources are CENSUS (IBGE) and Data SUS (Ministry of Health).In the second step a structured questionnaire with closed and semi-open questions was applied to health councilors, service providers and municipal public officials. Moreover, we collected data provided to official media for public announcements and mass media. The analysis of these materials helped in understanding the political context and the decisions made by each of the three administrations.In the third step we analyzed the distribution of health units and basic appointments as well as hospital admissions and sought to locate turning points that favored the equity gains identified in the first step. Once we identified these turning points we investigated the relationship between them and the policy decisions made by each of the three administrations, which were identified in the second step.

Results

Despite the fact that the SUS population was concentrated in the outskirts, in 2001 in the city of Sao Paulo equipment and services were concentrated in the central and oldest areas of the city of Sao Paulo. This meant that the populations who lived in areas with better socioeconomic indicators were privileged compared to populations living in the outskirts of the city. In this sense, it is important to note that the differences in distribution measured in the present work are between the poor that live in different areas of the city, rather than between poor and non-poor as such. The bias in favor of central areas was partially reversed in more recent years and this was made possible through heavy investment in infrastructure. The average number of basic health units per 20,000 SUS users increased from 0.79 to 1.42, and there was considerable progress in the distribution of these equipments to areas in the outskirts of the city. The implementation of new hospitals has privileged poorer areas, as can be noted by the fact that four out of five new hospitals built in this period were in areas among the 10 sub-municipalities with the lowest Human Development Index (MHDI) in the city. Along with this expansion there was a shift in the distribution of hospital beds: in 2001 the 9 sub-municipalities with the smallest MHDI supplied 5.75% of the public hospital beds in the municipality, while 10 years later this percentage had increased to 13.48%. It should also be noted that, in 2010, hospitalizations were 61.9% higher among SUS users residing in the first quartile (the poorest) and were only 13.8% higher among fourth quartile residents (the richest).The rate of primary appointments increased by 154.7% between 2001 and 2010, with the average rate of basic appointments per SUS user per year going from 1.28 to 3.26. From 2002 to 2006 the standard deviation in the distribution of these appointment between submunicipalities decreased from 0.93 to 0.66.The data collected and analyzed by the study clearly shows that there was significant expansion in the supply as well in the consumption of services in the regions that presented the worst socio-economic and health indicators. An analysis of the distribution of these resources also showed that we now have a more equitable distribution pattern of public health services between locations with a reduction in the geographic inequalities hindering access to the public health system.

Conclusion

The results described in the preceding section may seem expected, after all, the distribution of public health services was and still is biased towards wealthier areas and the correction of this situation is the most logical step. However, this is a striking result given how difficult it is to reverse this tendency as attested by the findings of a number of studies in different parts of the world, which indicate that the richest tend to persistently benefit more than the poorest from public spending on health (World Bank 2003; Liu, Hotchkiss and Bose 2007). The guidelines and programs established by the Brazilian Ministry of Health starting in the 1990s guaranteed that new resources reached the municipality. The simple use of these resources, replicating the distributive profile of the pre-existing equipment could, however, have easily led to a deepening of existing inequalities. As seen in the previous section, this was not what happened. From 2001, municipal managers began to take on a major role in proactively coordinating municipal policy and prioritizing those areas with higher populations of SUS users, which are the poorest areas and those with worse health indicators. The analysis suggests that the equity gains reported in the study happened trough cycles of micro and macro politics that reinforced each other. The micro cycles were lead by active local health councils which used political mobilization and contacts to pressure the municipal health secretariat for more resources. The macro cycles involved political projects and efforts by both the Workers' Party (PT), that held municipal office from 2001 until 2004, and the Brazilian Social Democracy Party (PSDB), which entered office in 2005. The equity gains made possible by the macro cycles were assured by the use of technical criteria to make sure that the new resources made available for basic health were distributed in a manner that would serve the population living in the municipality in a more equitable way. As it is described in detail in the study, these two dynamics, fed by political competition between PT and PSDB, allows for an explanation of the adoption of many of the policies that forged the distributive results described in the previous section.

1Institute of Population Health, University of Ottawa, Ottawa, Canada, 2Globalization and Health Equity Unit, University of Ottawa, Ottawa, Canada, 3Institute of Population Health, University of Ottawa, Edmonton, Canada.

Country - ies of focus

Canada

Relevant to the conference tracks

Governance and Policies

Summary

Canada has been regarded as a model global citizen with firm commitments to multilateralism. It has also played important roles in several international health treaties and conventions in recent years. There are now concerns that its interests in health as a foreign policy goal may be diminishing. This study reports on a thematic analysis of key Canadian foreign policy statements issued over the past decade, and interviews with key informants knowledgeable of, or experienced in the interstices of Canadian health and foreign policy.

Background

In 2007, the foreign ministers of seven countries (Norway, France, Brazil, Indonesia, Senegal, South Africa and Thailand) issued the Oslo Declaration identifying global health as ‘a pressing foreign policy issue of our time’. A number of government legislative, policy or commentary reports preceded and followed: Sweden’s policy on development, Switzerland’s health foreign policy, Norway’s Policy Coherence Commission and new white paper on global health in foreign and development policy, and the UK’s Health is Global strategy. In 2009, the US Institute of Medicine issued the second of two reports on global health in foreign policy, the same year that the Annual Ministerial Review held by the UN Economic and Social Council devoted itself to global public health. In November 2008 fifty-five nations sponsored a UN General Assembly Resolution on global health and foreign policy, urging member states ‘to consider health issues in the formulation of foreign policy’. Such developments serve to demonstrate a decadal trend in which health has risen to become an integral part of global policy discourse.

Objectives

Canada, until recently regarded as a pioneer in health multilateralism through its demonstration of leadership in the Ottawa Agreement to ban the use of anti-personnel landmines and in negotiations over the Framework Convention on Tobacco Control], has yet to produce any formal global health policy or framework. The lack of an explicit governmental policy does not necessarily mean that interest in the intersection of global health with foreign policy is absent. In 2010, for example, Health Canada commissioned two policy reviews to examine the bases for global health as a foreign policy goal. Further, two research projects were undertaken around the same time examining global health diplomacy in Canada, including the study we report on. Most recently, the Canadian Academy of Health Sciences (CAHS) completed an expert panel review of Canada’s strategic role in global health. These scholarly activities provide a base from which to examine the role of global health in Canada’s recent past, present and near-future foreign policy engagements. Our particular study set out to examine how global health has been considered in Canadian foreign policy. We were further interested in how global health is understood by Canadian foreign policy makers; is the perspective one that is narrowly focused only on disease and health/medical care (including drug research or access to essential medicines), or does it incorporate a broad understanding of the importance of social determinants of health? Relatedly, we wanted to explore which global health issues had most policy traction, which state or non-state actors are involved in framing health as a foreign policy goal, and what have been enabling or constraining factors in positioning health (and health equity) more prominently in Canadian foreign policy deliberations. In this study we focus on how health has been framed or defined as a foreign policy concern.

Methodology

Two methods were employed in our study. The first method involved a systematic document review and analysis of recent (post-2000) Canadian federal government policy statements on global or international health, or other policies and statements issued by federal Ministries or departments whose activities have strong if indirect bearing on health. Ten such documents were located. A discourse analysis of these documents was conducted searching for specific references to how health was framed as a policy issue. An initial template of policy framings, based upon earlier work by the researchers was used, followed by a thematic coding to ensure that novel rationales were also captured.
The second method was key informant interviews using purposive and snowball sampling. Thirteen (13) interviews were conducted with persons from the government, academic research and civil society sectors. All interviewees were recruited on the basis of their recent and current engagement in global health and foreign policy. Transcripts were returned to interviewees for member-checking if they so requested. Interview data were thematically coded with the assistance of qualitative data analysis software, NVivo.

Results

International relations scholars argue that national security and economic interests will often conflict with and inevitably trump that of global development and humanitarian aid, the domains within which most global health issues reside. Our study’s findings offer little evidence to challenge the supposition that health, when it does rise in Canadian foreign policy, does so primarily for instrumental reasons. Moreover, health is primarily and increasingly framed in relation to national security and economic interests. Little attention has been given to human rights obligations relevant to health as a foreign policy issue, and global health is not seen as a priority of the present government. Global health is nonetheless regarded as something with which Canadian foreign policy must engage, if only because of Canada’s membership in many United Nations and other multilateral fora. Development of a single global health strategy or framework is seen as important to improve intersectoral cooperation on health issues, and foreign policy coherence. There remains a cautious optimism that health could become the base from which Canada reasserts its internationalist status.

Conclusion

National security and global competitive advantage are playing the dominant roles in Canadian foreign policy. The challenge is how effectively, if at all, global health can find a position within such a framing, and without losing its moral or humanitarian base. Our own study findings are inconclusive on this point; although we found a keen desire for Canada to re-assert its presence in global health. We leave the last word on that count to one of our informants:
"[Health] is a win/win situation … It’s not like a trade issue, it’s not like a natural resources issue, it’s something that all countries can agree on [is] a benefit to their citizens. And I think if we can actually situate global health as a sort of a flagship of a renewed Canada foreign policy, I think that would be perceived extremely well by Canadians as being a reaffirmation of Canada’s engagement, in much the same way that we used to be considered as peace builders and peacekeepers internationally. I think Canadians are looking for that."

Rwanda has launched three prominent reforms in the field of health financing since 2000, which have shown significant results in increasing both the supply of and access to services. The fiscal decentralisation, the community-health insurance (mutuelles de santé), and the performance-based financing (PBF) have largely contributed to the fact that Rwanda is on good track in reaching the targeted health MDGs.
Funded by the Swiss Cooperation and Development Office since 2002, the Programme de Santa Publique – PSP (Public Health Programme) aims at strengthening the health system in two districts (Karongi and Rutsiro) in the Western Province.

What challenges does your project address and why is it of importance?

In the context of Rwanda, one of the main challenges is to reconcile the necessity to mobilise resources to ensure the financial viability of health services with a context of wide-spread poverty.
In the two districts of intervention, the project supported the setting-up of pilot mutuelles by providing management training for the staff of the mutuelle sections (sections are located within each health facility) and the mutuelle directions (at district level). This was done by providing tools, registrars and equipment and by monitoring the performances of sections and directions, as well as the financial flow between them and the health facilities. Early on, the project sought to include the dimensions of equity within the scheme and this was enacted by financially supporting the administrative districts to set-up the identification process of indigent people, and in turn by subsidising adherence fees and co-payments to health services utilisation via the mutuelle sections. This reduced health access barriers for this group. However, as close to 1/4th of the population is identified as indigent, a sustainable equity mechanism in covering the costs of the scheme (and not by external subsidising) is yet to be found.

How have you addressed these challenges? Do you see a solution?

Though previously scaled upon the basis of the socioeconomic status of households, the adherence fee has been fixed since 2007. This scheme does not allow a cross-subsidising of costs across the population. The PSP has supported a community solidarity mechanism for such cross-subsidising in each district. The Ikimana system is the grouping of 25 to 50 households into community associations where members motivate one another to pay their fees and assist members that are less well-off. This system has substantially raised the coverage of mutuelle in the two districts and shown that commitment and solidarity can be fostered amongst small groups who share a common reality. Policy dialogue has been conducted for the project about the gradual withdrawal of the subsidisation of indigent people in favour of other sources of funding, such as the Ikimana system. However, the taking-up of those groups by Ikimana has to be monitored in order to ensure that people are not left behind.Support of quality of care is challenging as because from the beginning the quality has always been relatively low due to the limited resources (financial, human and infrastructure) and the remoteness of some facilities. The concomitant reform introduced, Performance-based Financing (PBF), is expected to correct the negative effects of the utilisation increase by motiving the performance of the health staff in the facilities through incentives. However, most incentivised indicators of the PBF scheme are quantitative rather than qualitative. Ensuring a good quality of care is of primary importance to maintain the high adherence rate and the satisfaction of the insured. The PSP has supported the establishment of a monitoring system of quality of care (structure, process and results). It has also supported the conduct of client satisfaction surveys, which have shown fairly good levels of satisfaction. The project has also repeatedly conducted quality of care assessment in the intervention zone to evaluate the situation.

How do you know whether you have made a difference?

The PSP cannot claim to have made a difference on its own. The programme aims at supporting national policies and strategies. It has been observed in the two districts of intervention that the mutuelle adherence uptake is observed to be parallel with a marked increase in the utilisation rate, as well as an increase in the proportion of the indigent people within the general population that benefit from a free adherence card. The implementation of the mutuelle has not followed an experimental design, therefore establishing causality in the positive developments is not possible.
The PSP supported Karongi district was declared a model district in 2010, and has received a visit from the central level Mutuelles Technical Working Group. Other districts have subsequently visited Karongi’s direction and sections, to learn from their organisation and experiences. The mutuelle sections in the two districts are well organised, equipped and coordinated (at the national level), and they manage to cover the costs for the primary level.
At the national level, studies have shown that catastrophic expenditures have declined for all groups of the population. The approach has revealed not to be pro-poor, but neither pro-rich (Lu et al, 2012). In 2010, the government introduced a new measure to induce an increase in the utilisation by the poorest sections of the population by reducing the co-payments for such groups.

Have you or the project mobilized others and if so, who, why and how?

Firstly, the staff from the mutuelle sections and directions have been mobilised through the project. They have been trained, equipment and tools have been provided, and their performance has been monitored in order to provide tailored support. The support in their establishment as federations has also helped the coordination and organisation of their services in efficient ways. Ensuring the smooth functioning of mutuelle sections was a condition for the health facilities to remain financially viable. The project is structured so that the health services can be reimbursed by the sections of the health facilities. Delays in reimbursing the costs, as seen at the level of hospitals, can jeopardise the capacities of the health facilities.
It is undeniable that the observed success of the mutuelles in Rwanda is linked to the national political context. The government has declared adherence to a mutuelle as mandatory, and strong political will, with support from donors, has pooled the funds to ensure the establishment of the scheme and its financial viability in the first years. Setting performance targets for the local administration that included the increase in the adherence to mutuelles has also contributed to a very high coverage rate. Furthermore, Rwanda after 1994 has benefited from large external funding (in 2009, external funding represent 46% of the total health expenditures), which has facilitated the scheme's implementation.

When your donor funding runs out how will your idea continue to live?

Most of the support in implementing the mutuelle scheme in the two districts has been enacted in a way that the districts have substantial control. Direct financial support has been phased out between 2002 and 2013, and today the fees for indigent people are partially covered by communities through the Ikimana system. The district mutuelles are financially supported at the central level, with funds from the government and it’s partners such as the Global Fund.
The remaining main challenge is quality assurance. Continuous support is needed to ensure that the district level supervises and monitors the quality of care in the facilities. Supervision and monitoring of the financial flows are needed from the central level down to the district (directions) and the facilities (sections) to ensure the scheme's viablity.
The challenge for the mutuelle scheme is financial sustainability. Political instability in the region, mainly in neighbouring DRC where Rwanda plays a role, raises the concern of the international community and external funding may become fragile. Currently the financial viability of the system relies upon external funding, and if it diminished, financing the scheme at the secondary and tertiary levels could be at stake.

1Executive office, Center for the Study of Equity and Governance in Health Systems, Guatemala City, Guatemala, 2Field implementation, Center for the Study of Equity and Governance in Health Systems, Guatemala, Guatemala.

Country - ies of focus

Guatemala

Relevant to the conference tracks

Advocacy and Communication

Summary

Based on both human rights and health systems frameworks, a coalition of CSOs have been implementing a participatory approach to empower rural indigenous citizens to monitor public policies and health care services, demand actions to improve equitable resource allocation and shift power relations at the municipal level. The premise of this work is that strengthening health systems must be part of a larger effort to redress historical discrimination of population groups. In addition, the political empowerment of indigenous populations is a key condition to an equitable and responsive health system. After 5 years the approach has shown important positive results.

What challenges does your project address and why is it of importance?

Many health inequities are the expression of inequities of power in society. A history of discrimination, exploitation and 36 years of armed conflict in Guatemala has created unequal power relationships that place rural indigenous population at great disadvantage, suffering worse health outcomes than non-indigenous populations and facing many access barriers to existing services.

How have you addressed these challenges? Do you see a solution?

Following a human rights framework, a coalition of civil society organizations led by Centro de Estudios para la Equidad y Gobernanza en los Sistemas de Salud (CEGSS), have been implementing a participatory-action research approach aimed to empower rural indigenous citizens to monitor public policies and health care services, demand actions to improve equitable resource allocation and a shift power relations at the municipal level. The premise of this work is the understanding that in a context such as Guatemala, strengthening health systems must be part of a larger effort to redress historical discrimination. In addition, the political empowerment of indigenous population is a key condition to an equitable and responsive health system. The process includes the monitoring of health polices and services by community based indigenous organizations. The key characteristics are the following:
• Based on both a human rights framework and health systems strengthening.
• Citizens’ health boards carry-out the following activities:
– Surveying existing services to assess compliance with national standards (drugs availability, medical equipment, human resources)
– Document cases of families suffering hardship due to unmet healthcare needs
– Studying barriers to access (transport, discrimination, resource allocation)
– Submit a report to authorities
– Implement strategic advocacy to demand changes

How do you know whether you have made a difference?

Through ethnographic research and in-depth case studies, we have documented that our approach has had a positive impact in improving the availability of services at municipal level. It has also improved the level of trust between community based organizations and health authorities. Community leaders that have been part of this process also report “empowerment” and a motivation to expand their work. The health system is strengthened by improving resource allocation to benefit highly marginalized rural areas at the same time that health personnel develop skills to negotiate and respond to the user of services need. Overall, this approach is also strengthening democracy and promoting the social inclusion of indigenous populations.

Have you or the project mobilized others and if so, who, why and how?

Skills and knowledge to implement the approach have been transferred to other NGOs that work in different regions of the country. In addition, due to the relevance of the approach, we have managed to raise funding to expand the approach to 20 new rural indigenous municipalities of Guatemala.
We are also participating actively in several international networks (COPASAH: www.copasah.net) in which we are transferring our skills, knowledge and tools and also learning from other colleagues that participate in the networks.

When your donor funding runs out how will your idea continue to live?

A central component of our approach is the capacity-building of indigenous community leaders engaged in accountability and equity work. Up to June 2013, more than 400 community leaders from 15 different rural municipalities have been trained on community monitoring and social accountability of public polices and services. We are also transferring the skills to other civil society organizations present in these 15 municipalities. Since those organizations already have a presence in those municipalities and do not receive financial support from us, it is expected that they will continue to provide technical assistance to the community leaders once the skills and knowledge transfer process is completed. We are also active members of COPASAH (www.copasah.net) and TALEARN (http://www.transparency-initiative.org/news/talearners-safe-space). In both networks we are contributing to field building, hence the skills and knowledge shared in these two networks will remain with all the other member organizations